5- Urogenital traumas

Urogenital Trauma Overview

• Trauma patients: 3-10% have GU involvement; 10-15% with abdominal injuries have GU involvement.
• Types of Urogenital Injuries:
  • Renal & Ureteral Injury
  • Bladder Injury
  • Urethral Injury
  • Injuries of the external genitalia

Renal Injury

• Renal injuries: 45% of all GU injuries.
• Most (80%) renal injuries are minor and don't require surgery.
• Trauma can be blunt or penetrating.
• Motor vehicle accidents (MVAs) are a common cause.
• Grading scale of renal injuries exists (Grade I-V).

Renal Injury - Physical Exam

• Flank ecchymosis or mass indicates retroperitoneal process, but not specific to renal injuries.
• Gross or microscopic hematuria is the most important indicator of renal trauma.
• Absence of hematuria, though rare, doesn't exclude renal injury (absent in 5% of patients).

Renal Injury - Radiographic Staging

• IVP (intravenous pyelography): double dose
• CT Scan: best method for staging; preferred radiographic method
• Ultrasound
• Angiography: used for suspected renovascular injury.

CT Staging for Renal Injury

• Images (CT scans) shown depict renal stab wound (Grade IV) and a left renal laceration.

Management of Renal Injury

• Management depends on blunt or penetrating trauma and hematuria type.
  • Blunt: selective renal imaging, clinical follow-up
  • Penetrating: CT scan (IVP optional), selective renal exploration
• Stable vs unstable, based on the patient's condition

Surgical Management for Renal Injury

• Includes various procedures to repair different types of lacerations and injuries, illustrated with diagrams.

Ureteral Injury

• Ureteral injuries after violence are rare, less than 4% of penetrating trauma and less than 1% in blunt trauma cases.
• Unlike renal injuries, difficult to detect with usual diagnostic tools.
• Excratory urography demonstrates extravasation in the ureter (after a stab wound).

Surgical Management for Ureteral Injury

• Surgical management includes direct ureteroureterostomy, transureteroureterostomy, and reimplantation/psoas hitch procedures (illustrated).

Bladder Injury

• Classified into:
  • Extraperitoneal
  • Intraperitoneal
  • Contusions
• A full bladder is more susceptible to injury than an empty one.

Bladder Injury (cont.)

• Commonly occurs with blunt trauma (85% of cases), often with pelvic fractures.
• 15% occur with penetrating trauma without pelvic fracture (full bladder blowout).
• Gross hematuria in trauma settings requires imaging of both upper and lower urinary tracts.

Bladder Injury (cont.)

• Diagrams and descriptions illustrating various types of bladder injuries and their possible mechanisms. This includes blow to lower abdomen, pelvic fractures, or straddle injuries.

Diagnosis - Bladder Injury

• Cystogram and CT are diagnostic tools.
  • Cystogram (left): shows extraperitoneal bladder rupture with extravasation into the scrotum.
  • CT (right): reveals intraperitoneal bladder rupture with contrast material surrounding bowel loops (images included)

Surgical Management of Bladder Rupture

• Repair methods are illustrated to repair different rupture types.

Urethral Injury

• Almost exclusively in males.
• Common in straddle injuries.
• Significant morbidity, including:
  • Stricture
  • Incontinence
  • Impotence
• Foley catheter implications.

Urethral Injury (cont.)

• Posterior Urethra
  • Gross hematuria in 98% of cases
  • Inability to void
  • Blood at the urethral meatus
  • Pelvic/suprapubic tenderness, penile/scrotal/perineal hematoma, and a boggy/high-riding prostate mass on rectal examination.
• Anterior Urethra -More common than posterior -Direct Trauma -Usually NO pelvic injury -Blood at meatus -Unable to micturate -Penile/Scrotal/Perineal Contusion/Hematoma/Fluid collection

Urethra Injury - Intrapelic Rupture

• Diagrams illustrate the different types of injuries and their associated findings (e.g., urine and blood mass in the pelvis).

Diagnosis - Urethral Injury

• Urethrogram is the best diagnostic tool. -Images showing contrast extravasation into the bladder, suggesting partial or complete tear. Retrograde urethrography via meatus confirms this.

Management of Urethral Injury

• Partial tear: careful passage of a 12-14 French Foley catheter. If resistance, urologist intervention.
• Complete tear: Urology + suprapubic catheterization. If Foley is in place, leave it in place.
• Initial repair is not recommended due to risks of hemorrhage, impotence, and infection of pelvic hematoma.

Surgical Repair of Urethral Injury

• Illustrative diagrams showing surgical techniques like Bank's method for urethral repair.

Injuries of the External Genitalia

• Penis: Penetrating, skin avulsion, amputation repair with surgery.
  • Fracture repair and surgical drainage.
• Scrotum/testes: Hematocele and contusion (mild) or rupture (severe), requiring exploration.
  • Penetrating injuries need exploration.

Injuries of the External Genitalia (cont.)

• Images demonstrating penile fractures and scrotal hematomas after straddle injuries.

Test your knowledge on urogenital trauma, including types of injuries and the significance of renal trauma. This quiz covers the prevalence of GU injuries, key physical exam findings, and radiographic staging techniques. Perfect for medical students and professionals seeking to refresh their understanding of urogenital trauma.